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Treatment

Below you can find an overview of therapeutic options that can be used for the treatment of colorectal cancer.

Surgery

Treatment of colon cancer normally consists of an operation. These operations can be divided into two main catagories:
1. curative
2. relief of symptoms (palliative)

The curative operations are performed by a scopic procedure. A major advantage is that only small incisions in the abdomal wall would have to be made, which enhances recovery afterwards. Another advantage is the cosmetic result after surgery. However, when the scopic procedure is not (longer) applicable, the surgeon will decide to convert to an conventional (open) procedure. This includes opening the abdomen with a vertical incision.

Curative surgery
During the operation tumor and surrounding tissue, which may appear healthy, are removed together with lymph nodes in proximity and nourishing blood vessels. This procedure aims to reduce chances on tumor cells that are left behind after the operation. This leaves two bowel ends which can then be connected (anastomosis), in almost all cases.

In some cases a anastomosis is not possible. This may occur when the local condition of the tissue is suboptimal. In this case the bowel will leave the abdomen through an alternative exit in the abdominal wall (stoma). The remainder part of the bowel, c.q. the other end, will be closed en left behind in the abdominal cavity. The two ends may, in a later phase, be connected after all. When a stoma is obtained, feces will exit via the new route and collected in a small bag that sticks to the abdominal wall surrounding the stoma.

When the tumor is located in the rectum, conservation of the sphincter is dependent on the distance of the tumor to the sphincter. When possible, a connection between the colon and rectum (or sphincter) is obtained. However, to ensure full tissue recovery a temporarily stoma may be needed which is abolished after 2-3 months. In case such a connection is not possible, a definitive stoma is obtained after removal of the whole sphincter-complex and (part of) the rectum. In this case the whole peri-anal surrounding tissue will be closed.

In case of one or more metastases in the liver and/or lung(s), it should be considered to also surgically remove these.

Palliative surgery
A non-removable metastases is defined when other areas of the body a affected or when there is severe growth of the tumor itself. This treatment is not aimed to cure but rather to relief symptoms caused by impenetrable part of the bowel. During the operation the tumor can be (partly) removed to ensure bowel continuity. Or, in case this is not possible, a stoma is constructed. Another alternative is to construct bypass between healthy tissue of the bowel to ensure continuity of feces. The newest alternative is placement of a tube (stent) within the tumor region to push the bowel wall outward. This procedure is performed by endoscope (colonoscopy). This treatment is not yet standard of care.

Endoscopy

Endoscopy

Endoscopy

During the endoscopic investigation of the bowel polyps and early stage cancer spots may be removed. The removed tissue is than explored under the microscope. In case a superficial tumor was found in the rectum, this may be removed by local surgery. This procedure contains of a scopic assisted surgery via the anal opening. This is called trans-anal endoscopic microsurgery (TEM).

To determine if a tumor can be surgically removed, a preparatory endo-ultrasound is performed. In case of a palliative treatment an optional approach is to cause destruction of the tumor by laser beam coagulation during the endoscopic procedure. This is executed by electro coagulation. Only in small tumors located in the rectum, which are fairly reachable, this accounts as an alternative treatment.

Radiotherapy

Radiation is mostly performed in patients with rectal cancer. Through irradiation of the tumor the individual cancer cells are destructed. This radiaton beam is not visible to the eye and can not be felt. However, fatigue and redness of the skin are possible side effects of radiation.

Radiotherapy can both be administered in a curative or palliative setting. Radiation is performed by a radiation beam aimed from the outside to the inner body. The dose of radiation needed is calculated by the radiation oncologist for each individual case. A CT scan is needed for these calculations. Patients who undergo radiation treatment are mostly treated in daily on an outpatient basis, and does not require hospital admission.

In case of a rectal cancer radiation is performed prior to surgery. Main reasons are 1) to reduce lifespan of the tumor cells in order to reduce risk of left behind tumor cells which might outgrow in to new tumors after the operation. And 2) to downsize the initial tumor in order for the tumor to be removed safer and more easily.

Two types of radiation can be considered:
– Short course radiotherapy consisting of 5 fractions within the same week. Surgery will follow in the week following radiation.
– Long course radiotherapy consisting of 25 fractions over the course of five weeks. After radiation surgery takes place between 8-10 weeks afterwards to ensure downsizing of the tumor. This radiation scheme is often combined with chemotherapy to increase its effect.

Choice for one the above radiation schedules is dependent on location, outgrowth and size of the tumor. If, during or after surgery, it becomes clear that tumor has been left behind in the patient post-radiation (adjuvant radiotherapy) is considered. If the surgical wound have healed, a (new) course of radiation is started.

All the treatment options discussed above are curative applications of radiotherapy. However, radiotherapy can also be applied when surgery is not an option. In this case radiation is part of a palliative treatment. Radiation then aims to reduce pain, contain bowel continuity and reduction of blood loss.

Chemotherapy

Chemotherapy is a form of treatment that aims to inhibit cell division. There are several different types of drugs with different schemes and different administration routes. Per patient a tailored plan is offered which is best suited for the patient. Usually the drugs are administered to the patient by infusion, this will take place in the outpatient clinic. Sometimes it is necessary to insert a port-a-cath, which is an infusion box connected to a blood vessel. This makes the administration of drugs easier and more comfortable for the patient.

Nowadays there are also drugs that can be administered orally. Often several drugs are combined at the same time. Most schemes have one week of administration, followed with two to three weeks of rest. This will be repeated in six cycles. Chemotherapy in colorectal cancer patients is not only directed to the primary tumor in the intestine, but also treatment for possible metastases. Patients with colorectal cancer without metastases to other organs (e.g. the liver) will get chemotherapy when metastasis in the lymph nodes are diagnosed by the pathologist after surgery. This chemotherapy treatment is part of the curative treatment and is given to prevent any other metastases to occur.

Chemotherapy may also be given when metastases in other organs are detected, this will be as a palliative treatment. The purpose of this treatment is to reduce symptoms and to be life-sustaining. In addition, sometimes a curative operation is possible after chemotherapy treatment.

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